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HomeMy WebLinkAboutPermit Mechanical 1994-4-18 WOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD . BUILDING SAFETY DIVISION u&R 225 Fifth' Street Springfield, Oregon 97477 Office: 726~3759 INSPECTION LINE: 726-3769 Job Locadon: 35"3 ,~(?lds~ Sp0r\~'~fJd" DR-- ,Qllfi7 .,', ',' ',:'., \nQ~'~~' Tax Lot #: O~1n() Assessors Map #: - ' Owne~:thu\d. ~ [)t\V\f\Cl 'Sp(de.-il , ,~ " " " , , Address: ~S2) ~I ?\r1csinne_ City: L~V(Vl,~PLd' State: Value of Y, od Stov /Pellet Stove/Insert: (plea e appropriate appliance) Phone #: ~zIb -(dlcf~ Zip: C/i1f77 (91- {\ (\ ) Prelimin~ry Inspection is $15.00 (prior to installation of insert) . Wood Stove/Pellet/Insert permi~s $15jOO + $ .75 state surcharge + Type of Inspection Requested: \{)\ 01. Q f'f\.L(\;D...5LA..l . Q $10.00 Issuance. Contractor: f\~ Address: Phone #: City: State: Zip: Construction Contractors Registration #: "il) 4 t By signing this permit/application, I agree to call for an inspection(s) as required (726-3769). I state that all information on this application/permit is correct and that I was proviqed with the Wood Stove Safety information for wood burning appliances and preliminary inspection standards. I further state that the appliance I am installing meets smoke emission standards as set by the Oregon Department of Environmental Quality or the Federal Environmental Protection Agency and I agree to provide the testing approval number to the inspector at the tim~ of inspection. I also understand that if I am requesting a preliminary inspection, the wall covering may be required to be.removed. [)dJ{;Y(il d 4wM1 Signature / Expires: 2j -ffrr!j sL Date I FOR OFFICE USE Date of Application: VOODSTOVE/PELLET/INSERT O. ca.q~ \~,~ Job #: . PREL~NARr )( c{4CJ(c11\ REQUIRED INSPECTION(S): Total Amount Collected: Receipt II \l\\n1:9\ I () Issued By: ~ Checked for Delinquencies: for Historical Status: